Best Practice STI Treatment in Children
Critical Initial Consideration
All children with sexually transmitted infections should be evaluated for sexual abuse, and only culture-based diagnostic methods should be used for medico-legal purposes—non-culture tests (DNA probes, EIA, Gram stain) are not acceptable for diagnosis in children. 1
Diagnostic Requirements
- Use only standard culture systems for isolation of N. gonorrhoeae in children due to potential medical/legal implications 1
- Specimens from vagina, urethra, pharynx, or rectum must be streaked onto selective media 1
- All presumptive isolates must be confirmed by at least two tests using different principles (biochemical, enzyme substrate, or serologic) 1
- Preserve all isolates to permit additional or repeated testing 1
- All children with gonococcal infections must be evaluated for coinfection with syphilis and C. trachomatis 1
Treatment Regimens by Weight and Infection Type
Children Weighing ≥45 kg
Treat with adult regimens for all STIs 1
Note: Fluoroquinolones are not FDA-approved for children <18 years, though no joint damage has been clearly documented in pediatric use 1
Children Weighing <45 kg with Uncomplicated Gonococcal Infections
For vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis:
- Recommended: Ceftriaxone 125 mg IM as a single dose 1
- Alternative: Spectinomycin 40 mg/kg (maximum 2 g) IM as a single dose 1
- Caveat: Spectinomycin is unreliable for pharyngeal infections and requires follow-up culture 1
Children with Complicated Gonococcal Infections (Bacteremia or Arthritis)
For children <45 kg:
- Ceftriaxone 50 mg/kg (maximum 1 g) IM or IV once daily for 7 days 1
For children ≥45 kg:
- Ceftriaxone 50 mg/kg IM or IV once daily for 7 days (some guidelines extend to 10-14 days) 1
Chlamydial Infections
For children ≥8 years old:
- Doxycycline 100 mg orally twice daily for 7 days 1, 2, 3
- Dosing for children >8 years: 2 mg/lb body weight divided into two doses on day 1, then 1 mg/lb daily (or divided twice daily) thereafter 2
For children <8 years old:
- Azithromycin 1 g orally as a single dose (extrapolated from adult dosing) 4, 5
- Critical pitfall: Never use tetracyclines in children <8 years due to tooth discoloration and bone growth effects 2
Sexual Assault/Abuse Prophylaxis
When sexual assault is confirmed or strongly suspected, empiric treatment should cover chlamydia, gonorrhea, trichomoniasis, and bacterial vaginosis:
- Ceftriaxone 125 mg IM as a single dose 1
- PLUS Metronidazole 2 g orally as a single dose 1
- PLUS Doxycycline 100 mg orally twice daily for 7 days (only if ≥8 years old) 1
For children <8 years, substitute azithromycin for doxycycline 4
Syphilis Treatment in Children
For early syphilis (<1 year duration):
- Penicillin G benzathine 2.4 million units IM as a single dose 3
For syphilis >1 year or unknown duration:
- Penicillin G benzathine 2.4 million units IM weekly for 3 consecutive weeks 3
For neurosyphilis, ocular, or otic syphilis:
- Aqueous crystalline penicillin G IV for 10-14 days 3
Neonatal Prophylaxis
Ophthalmia neonatorum prevention (required by law in most states):
- Erythromycin 0.5% ophthalmic ointment as a single application 1
- OR Tetracycline 1% ophthalmic ointment as a single application 1
- Instill into both eyes immediately after delivery, regardless of delivery method 1
Silver nitrate 1% was previously recommended but is less commonly used now 1
Follow-Up Requirements
- No follow-up cultures needed if ceftriaxone is used for gonococcal infections 1
- Follow-up culture is mandatory if spectinomycin is used for pharyngeal gonorrhea 1
- Follow-up cultures from all infected sites are necessary to confirm treatment effectiveness when using alternative regimens 1
Critical Pitfalls to Avoid
- Never use oral cephalosporins (cefixime, cefuroxime, cefpodoxime) in children—they lack adequate pediatric evaluation 1
- Only parenteral cephalosporins are recommended: ceftriaxone for all gonococcal infections; cefotaxime only for gonococcal ophthalmia 1
- Do not use non-culture diagnostic tests in children due to medico-legal implications 1
- Always screen for co-infections (syphilis and chlamydia) when gonorrhea is diagnosed 1
- Mandatory reporting and evaluation for sexual abuse when STIs are identified in prepubertal children 1, 6